Healthcare Provider Details

I. General information

NPI: 1699226712
Provider Name (Legal Business Name): PEGGY BAIN DVM, MPH, DACVPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2016
Last Update Date: 10/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49620 BELUGA RD BLDG 194, RM 111
SAN DIEGO CA
92152-6505
US

IV. Provider business mailing address

53560 HULL ST
SAN DIEGO CA
92152-5001
US

V. Phone/Fax

Practice location:
  • Phone: 619-553-1869
  • Fax: 619-553-6295
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number19157
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: